HRSA 99-2 (Initial)

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Department of Health and Human Services
Health Resources and Services Administration

OMB N0. 0915-0247
Expiration Date: XX/XX/20XX

CHILDREN’S HOSPITALS GRADUATE MEDICAL
EDUCATION PAYMENT PROGRAM
APPLICATION FORM HRSA 99-2

Public Burden Statement

An agency may not conduct or sponsor, and a person is not required to respond to, a
collection of information unless it displays a currently valid OMB control number. The
OMB control number for this project is 0915-0247. Public reporting burden for this
collection of information is estimated to average 11.33 hours per response, including the
time for reviewing instructions, searching existing data sources, and completing and
reviewing the collection of information. Send comments regarding this burden estimate or
any other aspect of this collection of information, including suggestions for reducing this
burden, to HRSA Reports Clearance Officer, 5600 Fishers Lane, Room 10-29, Rockville,
Maryland, 20857.

Department of Health and Human Services
Health Resources and Services Administration

OMB N0. 0915-0247
Expiration Date: XX/XX/20XX

Children's Hospitals Graduate Medical Education Payment Program
Determination of Indirect Medical
Education Data
Related to the Teaching of Residents
Name of Applicant:
0
City
0
State
Medicare Provider Number
0
Fiscal Year in which Applying for Funding:
Type of Application (check box to the left)

0

Zip Code: 0
FFY
____Initial Application

______Reconciliation Application

Inpatient Data for the Current Medicare Cost Report (MCR) Period
1.01
1.02
1.03
1.04

Inclusive dates of the current MCR period
From:
To:
Number of Inpatient Days
Number of Inpatient Discharges
Case Mix Index (CMI)
Hospitals that elect not to submit a CMI are required to initial the box to
the left acknowledging their ineligibility for IME payments. The initials to
the left must be consistent with the signature on HRSA 99-3.

IRB Ratio for the Current MCR Period
1.05
1.06
1.07

3-year adjusted unweighted resident FTE rolling average for the
current MCR period
Bed count for the current MCR period
IRB ratio for the current MCR period

1.08

Inclusive dates of the previous MCR period

1.09
1.10
1.11

Unweighted resident FTE count for the previous MCR period
Bed count for previous MCR period
IRB ratio for the previous MCR period

1.12

IRB Cap (lesser of 1.07 or 1.11)

1.13

§422 of the MMA unweighted resident FTE count for the
current MCR period
Bed count for the current MCR period
§422 of the MMA IRB ratio for the current MCR period

0.00
0
0.000000

IRB Ratio for the Previous MCR Period
From:

To:
0.00
0.00
0.000000

IRB Cap
0.000000

§422 of the MMA IRB Ratio for the Current MCR Period
1.14
1.15

0.00
0.00
0.000000

Outpatient Data
1.16
1.17
1.18
1.19
1.20

Number of Ambulatory Surgery Visits
Number of Radiology Visits
Number of Urgent Care Visits
Number of Emergency Department Visits
Number of Clinic Visits

HRSA 99-2 Page 1 of 1

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Created in MS Excel 7.0

(Rev. 04-2016)